Point of Sale (POS) Pharmacy Drug Prior Authorization Instructions – (click here for instructions)
Change Healthcare is the MS DOM vendor for Fee For Service drugs billed through the POS venue. If you are a Mississippi Medicaid prescriber, please submit your Fee For Service prior authorization requests through the Change Healthcare web portal, or please contact the Change Healthcare Pharmacy PA Unit at the following:
Toll-free: 877-537-0722
Fax: 877-537-0720
For MSCAN drug prior authorizations, please click here for MSCAN plan prior authorization contact information.
Please utilize the drop-down menus below to select the appropriate PA packet.
Prior Authorization Packets
| Prior Authorization Packets | Updated |
|---|---|
| Brand Name Multi-Source | 6/21/2019 |
| Early Refill | 6/21/2019 |
| Enteral Nutrition | 6/21/2019 |
| EPSDT – Beneficiaries Under 21 | 6/28/2019 |
| Growth Hormone | 10/1/2021 |
| Hepatitis C Therapy | 3/1/2022 |
| Max Unit Override | 6/21/2019 |
| Multiple Concurrent Antipsychotics for Beneficiaries (Age < 18) | 6/21/2019 |
| Opioid Packet – Effective 8/1/2019 FAQs | 9/10/2019 |
| PDL Exception Request | 6/21/2019 |
| RSV-SYNAGIS®
Mississippi Medicaid coverage of Synagis for the 2021-2022 RSV season will end on March 31, 2022 |
9/30/2021 |
| Universal Prior Authorization Form | 6/21/2019 |
Manual PA Criteria
| Manual Prior Authorization Criteria | Updated |
|---|---|
| Akynzeo | 2/3/2020 |
| Antipsychotics | 2/3/2020 |
| Austedo | 6/10/2020 |
| CGRPs | 5/26/2021 |
| Corlanor | 2/3/2020 |
| Cresemba | 2/3/2020 |
| Dupixent – Asthma | 2/3/2020 |
| Dupixent – Atopic Dermatitis | 2/3/2020 |
| Dupixent – Nasal Polyposis | 12/27/2021 |
| Emflaza | 4/28/2022 |
| Endari | 2/3/2020 |
| Eucrisa | 4/1/2020 |
| Evrysdi | 4/6/2021 |
| Exondys | 2/3/2020 |
| Farydak | 2/3/2020 |
| Hemlibra | 2/3/2020 |
| Ingrezza | 2/3/2020 |
| Jadenu | 2/3/2020 |
| Juxtapid | 2/3/2020 |
| Kalydeco | 1/27/2021 |
| Lotronex | 2/3/2020 |
| Lynparza | 6/3/2020 |
| Mavenclad | 2/3/2020 |
| Mayzent | 2/3/2020 |
| Ocrevus | 2/3/2020 |
| Orkambi | 2/3/2020 |
| Oxbryta | 5/9/2022 |
| Palforzia | 12/16/2020 |
| Praluent | 10/27/2019 |
| Probuphine | 2/3/2020 |
| Repatha | 10/16/2019 |
| Sivexto | 2/3/2020 |
| Stribild | 2/3/2020 |
| Sublocade | 2/3/2020 |
| Symdeko | 1/27/2021 |
| Trikafta | 7/9/2021 |
| Tybost | 2/3/2020 |
| Varubi | 2/3/2020 |
| Viltepso | 1/21/2021 |
| Vivitrol | 2/3/2020 |
| Vyepti | 2/10/2021 |
| Vyondys 53 | 1/22/2021 |
| Zontivity | 2/3/2020 |
| Zyvox | 2/3/2020 |
Physician Administered Drug (PAD) Prior Authorization Instructions
Alliant Health Solutions is the current vendor responsible for prior authorization requests for fee-for-service (FFS) Medicaid beneficiaries. Please click here to direct you to the Alliant official website, or call Alliant directly at 1-888-224-3067. Providers are encouraged to register with Alliant as soon as possible to submit authorization requests via the Alliant web portal. Drug criteria may be found on the Help/Support page. For a listing of drugs that require a PA, please click one of the options below.
